No change in the incidence of ampicillin-resistant, neonatal, early-onset sepsis over 18 years

Urinary Tract Infection Epidemiology in NICUs in the United States

OBJECTIVE

Our objective was to characterize the incidence, associated clinical factors, timing of infection, microbiology, and incidence of concordant blood culture of urinary tract infections (UTIs) in very low birth weight (VLBW <1,500g) infants.

STUDY DESIGN

Multicenter observational cohort study of VLBW infants with gestational age (GA) ≤32 weeks, still hospitalized on postnatal day 7, and discharged 2010 to 2018 from Pediatrix Medical Group neonatal intensive care units. Demographic and clinical characteristics of infants with and without UTI were compared. Multivariable logistic regression evaluated adjusted odds of UTI diagnosis.

RESULTS

Of 86,492 included infants, 5,988 (7%) had a UTI. The most common pathogen was Enterococcus spp. (20%), followed by Escherichia coli (19%) and Klebsiella spp. (18%). Candida spp. (6%) was the most common nonbacterial pathogen. Concordant-positive blood culture was present in 8% of infants with UTI diagnoses. UTI was associated with lower GA, male sex, vaginal delivery, prenatal steroid exposure, and longer duration of hospitalization.

CONCLUSION

UTI is a common cause of infection in VLBW infants, especially among the smallest, most premature, male infants, and those with a longer duration of hospitalization. Neonatal clinicians should consider obtaining urine culture in the setting of late-onset sepsis evaluations in VLBW infants.

KEY POINTS

· UTI is a common cause of LOS in VLBW infants.. · The most common pathogens are Enterococcus spp. and E. coli.. · UTI risk varies among different VLBW infant populations.. · Next steps should include evaluation of preventative measures..

Risk and diagnostic factors and therapy outcome of neonatal early onset sepsis in ICU patients of Saudi Arabia: a systematic review and meta analysis

Background

Neonatal early onset sepsis (NEOS) is a serious and potentially life-threatening condition affecting newborns within the first few days of life. While the diagnosis of NEOS was based on clinical signs and symptoms in the past, recent years have seen growing interest in identifying specific diagnostic factors and optimizing therapy outcomes. This study aims to investigate the diagnostic and risk factors and therapy outcomes of neonatal EOS in ICU patients in Saudi Arabia, with the goal of improving the management of neonatal EOS in the country.

Methods

This method outlines the protocol development, search strategy, study selection, and data collection process for a systematic review on neonatal early onset sepsis in Saudi Arabian ICU patients, following the PRISMA 2020 guidelines. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) is a well-established guideline that provides a framework for conducting systematic reviews and meta-analyses in a transparent and standardized manner. It aims to improve the quality and reporting of such research by ensuring clear and comprehensive reporting of study methods, results, and interpretations. The search strategy included electronic databases (PubMed, Embase, Google Scholar, Science Direct, and the Cochrane Library) and manual search of relevant studies, and data were extracted using a standardized form.

Results

The systematic review included 21 studies on neonatal sepsis in Saudi Arabia, with varying study designs, sample sizes, and prevalence rates of sepsis. Group B streptococcus and E. coli were the most commonly isolated pathogens. Various diagnostic factors and risk factors were reported, including hematological parameters, biomarkers, and blood cultures. The quality of the included studies was assessed using the Newcastle-Ottawa Scale and Joanna Briggs Institute critical checklist.

Conclusions

The review identified a number of risk and diagnostic factors and therapy outcomes for neonatal sepsis. However, most of the studies were having small scale cohort groups. Further research with controlled study designs is needed to develop effective prevention and management strategies for neonatal sepsis in Saudi Arabia.

Interspecies Interactions within the Host: the Social Network of Group B Streptococcus

Group B Streptococcus (GBS) is a pervasive neonatal pathogen accounting for a combined half a million deaths and stillbirths annually. The most common source of fetal or neonatal GBS exposure is the maternal microbiota. GBS asymptomatically colonizes the gastrointestinal and vaginal mucosa of 1 in 5 individuals globally, although its precise role in these niches is not well understood. To prevent vertical transmission, broad-spectrum antibiotics are administered to GBS-positive mothers during labor in many countries. Although antibiotics have significantly reduced GBS early-onset neonatal disease, there are several unintended consequences, including an altered neonatal microbiota and increased risk for other microbial infections. Additionally, the incidence of late-onset GBS neonatal disease remains unaffected and has sparked an emerging hypothesis that GBS-microbe interactions in developing neonatal gut microbiota may be directly involved in this disease process. This review summarizes our current understanding of GBS interactions with other resident microbes at the mucosal surface from multiple angles, including clinical association studies, agriculture and aquaculture observations, and experimental animal model systems. We also include a comprehensive review of in vitro findings of GBS interactions with other bacterial and fungal microbes, both commensal and pathogenic, along with newly established animal models of GBS vaginal colonization and in utero or neonatal infection. Finally, we provide a perspective on emerging areas of research and current strategies to design microbe-targeting prebiotic or probiotic therapeutic intervention strategies to prevent GBS disease in vulnerable populations.

Patterns of Infections among Extremely Preterm Infants

Infections remain a leading cause of neonatal death, especially among the extremely preterm infants. To evaluate the incidence, pathogenesis, and in-hospital outcomes associated with sepsis among hospitalized extremely preterm infants born at 24-0/7 to 27-6/7 weeks of gestation, we designed a post hoc analysis of data collected prospectively during the Preterm Epo Neuroprotection (PENUT) Trial, NCT #01378273. We analyzed culture positive infection data, as well as type and duration of antibiotic course and described their association with in-hospital morbidities and mortality. Of 936 included infants, 229 (24%) had at least one positive blood culture during their hospitalization. Early onset sepsis (EOS, ≤3 days after birth) occurred in 6% of the infants, with Coagulase negative Staphylococci (CoNS) and Escherichia Coli the most frequent pathogens. Late onset sepsis (LOS, >day 3) occurred in 20% of the infants. Nearly all infants were treated with antibiotics for presumed sepsis at least once during their hospitalization. The risk of confirmed or presumed EOS was lower with increasing birthweight. Confirmed EOS had no significant association with in-hospital outcomes or death while LOS was associated with increased risk of necrotizing enterocolitis and death. Extremely premature infants with presumed sepsis as compared to culture positive sepsis had lower rates of morbidities. In conclusion, the use of antibiotics for presumed sepsis remains much higher than confirmed infection rates. Ongoing work exploring antibiotic stewardship and presumed, culture-negative sepsis in extremely preterm infants is needed.

Early Diagnosis of Late-Onset Neonatal Sepsis Using a Sepsis Prediction Score

Sepsis represents a common cause of morbidity in the Neonatal Intensive Care Unit (NICU). Our objective was to assess the value of clinical and laboratory parameters in predicting septicemia (positive blood culture) in NICU infants. In the first part of the present study (derivation cohort) we retrospectively reviewed the clinical files of 120 neonates with symptoms of suspected sepsis and identified clinical and laboratory parameters associated with proven sepsis on the day the blood culture was taken, as well as 24 h and 48 h earlier. These parameters were combined into a sepsis prediction score (SPS). Subsequently (validation study), we prospectively validated the performance of the SPS in a cohort of 145 neonates. The identified parameters were: temperature instability, platelet count < 150,000/mm³, feeding volume decrease > 20%, changes in blood glucose > 50%, CRP > 1 mg/dL, circulatory and respiratory deterioration. In the retrospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 82.54% sensitivity, 85.96% specificity, 5.88 PLR (Positive Likelihood Ratio), 0.20 NLR (Negative Likelihood Ratio), 86.67% PPV (Positive Predictive Value), 81.67% NPV (Negative Predictive Value) and 84.17% accuracy. In the prospective cohort, on the day the blood culture was obtained, a SPS ≥ 3 could predict sepsis with 76.60% sensitivity, 72.55% specificity, 2.79 PLR, 0.32 NLR, 83.72% PPV, 62.71% NPV and 75.17% accuracy. We concluded that this combination of clinical and laboratory parameters may assist in the prediction of septicemia in NICUs.

Early-onset sepsis in very preterm neonates in Australia and New Zealand, 2007-2018

OBJECTIVE

To evaluate the epidemiology and population trends of early-onset sepsis in very preterm neonates admitted to neonatal intensive care units (NICU) in Australia and New Zealand.

DESIGN

Retrospective observational cohort study using a dual-nation registry database.

SETTING

29 NICUs that have contributed to the Australian and New Zealand Neonatal Network.

PARTICIPANTS

Neonates born at <32 weeks' gestation born between 2007 and 2018 and then admitted to a NICU.

MAIN OUTCOME MEASURES

Microorganism profiles, incidence, mortality and morbidity.

RESULTS

Over the 12-year period, 614 early-onset sepsis cases from 43 178 very preterm admissions (14.2/1000 admissions) were identified. The trends of early-onset sepsis incidence remained stable, varying between 9.8 and 19.4/1000 admissions (linear trend, p=0.56). The leading causative organisms were Escherichia coli (E. coli) (33.7%) followed by group B Streptococcus (GBS) (16.1%). The incidence of E. coli increased between 2007 (3.2/1000 admissions) and 2018 (8.3/1000 admissions; p=0.02). Neonates with E. coli had higher odds of mortality compared with those with GBS (OR=2.8, 95% CI 1.2 to 6.1). Mortality due to GBS decreased over the same period (2007: 0.6/1000 admissions, 2018: 0.0/1000 admissions; p=0.01). Early-onset sepsis tripled the odds of mortality (OR=3.0, 95% CI 2.4 to 3.7) and halved the odds of survival without morbidity (OR=0.5, 95% CI 0.4 to 0.6).

CONCLUSION

Early-onset sepsis remains an important condition among very preterm populations. Furthermore, E. coli is a dominant microorganism of very preterm early-onset sepsis in Australia and New Zealand. Rates of E. coli have been increasing in recent years, while GBS-associated mortality has decreased.

Bacterial, fungal, and interkingdom microbiome features of exclusively breastfeeding dyads are associated with infant age, antibiotic exposure, and birth mode

The composition and function of early life gut bacterial communities (microbiomes) have been proposed to modulate health for the long term. In addition to bacteria, fungi (mycobiomes) also colonize the early life gut and have been implicated in health disorders such as asthma and obesity. Despite the potential importance of mycobiomes in health, there has been a lack of study regarding fungi and their interkingdom interactions with bacteria during infancy. The goal of this study was to obtain a more complete understanding of microbial communities thought to be relevant for the early life programming of health. Breastmilk and infant feces were obtained from a unique cohort of healthy, exclusively breastfeeding dyads recruited as part of the Mothers and Infants Linked for Healthy Growth (MILk) study with microbial taxa characterized using amplicon-based sequencing approaches. Bacterial and fungal communities in breastmilk were both distinct from those of infant feces, consistent with niche-specific microbial community development. Nevertheless, overlap was observed among sample types (breastmilk, 1-month feces, 6-month feces) with respect to the taxa that were the most prevalent and abundant. Self-reported antibacterial antibiotic exposure was associated with micro- as well as mycobiome variation, which depended upon the subject receiving antibiotics (mother or infant), timing of exposure (prenatal, peri- or postpartum), and sample type. In addition, birth mode was associated with bacterial and fungal community variation in infant feces, but not breastmilk. Correlations between bacterial and fungal taxa abundances were identified in all sample types. For infant feces, congruency between bacterial and fungal communities was higher for older infants, consistent with the idea of co-maturation of bacterial and fungal gut communities. Interkingdom connectedness also tended to be higher in older infants. Additionally, higher interkingdom connectedness was associated with Cesarean section birth and with antibiotic exposure for microbial communities of both breastmilk and infant feces. Overall, these results implicate infant age, birth mode, and antibiotic exposure in bacterial, fungal and interkingdom relationship variation in early-life-relevant microbiomes, expanding the current literature beyond bacteria.

Epidemiological evolution of early-onset neonatal sepsis over 12 years: A single center, population-based study in central Taiwan

BACKGROUND

We aimed to explore the epidemiology and evolution of pathogens, antibiotic susceptibility, and mortality rate in cases of neonatal early-onset sepsis (EOS) reported over a period of 12 years in a level III neonatal center in Central Taiwan.

METHODS

Patients' medical records in a neonatal center from 2007 to 2018 were reviewed to obtain information on infants with culture-proven EOS, which included pathogens found in the blood or cerebrospinal fluid cultures.

RESULTS

The incidence of neonatal EOS during this period was 2.11 cases/1,000 admissions. Group B streptococcal (GBS) and Escherichia coli were the most common pathogens. The overall rates of GBS and E. coli infections were 0.68/1,000 and 0.77/1,000 live births, respectively. The incidence of EOS in infants with a birth weight ≥1,500 g decreased significantly with decreasing incidence of GBS-related sepsis. The incidence of EOS remained high in very-low-birth-weight (VLBW) infants and increased over time. There was an increasing trend in of E. coli infection and emergence of drug-resistant strains. In addition, E. coli sepsis had high mortality in VLBW infants.

CONCLUSION

Novel screening and prevention strategies against E. coli and reserving broad-spectrum antibiotics for the most critically ill or VLBW patients with maternal chorioamnionitis might help in early diagnosis and further improve the outcomes of EOS.

Antibiotic prophylaxis in preterm premature rupture of membranes at 24-31 weeks' gestation: perinatal and 2-year outcomes in the EPIPAGE-2 cohort

Objective

To compare different antibiotic prophylaxis administered after preterm premature rupture of membranes to determine whether any were associated with differences in obstetric and/or neonatal outcomes and/or neurodevelopmental outcomes at 2 years of corrected age.

Design

Prospective, nationwide, population‐based EPIPAGE‐2 cohort study of preterm infants.

Setting

France, 2011.

Sample

We included 492 women with a singleton pregnancy and a diagnosis of preterm premature rupture of membranes at 24–31 weeks. Exclusion criteria were contraindication to expectant management or indication for antibiotic therapy other than preterm premature rupture of membranes. Antibiotic prophylaxis was categorised as amoxicillin (n = 345), macrolide (n = 30), third‐generation cephalosporin (n = 45) or any combinations covering Streptococcus agalactiae and >90% of Escherichia coli (n = 72), initiated within 24 hours after preterm premature rupture of membranes.

Methods

Population‐averaged robust Poisson models.

Main Outcome Measures

Survival at discharge without severe neonatal morbidity, 2‐year neurodevelopment.

Results

With amoxicillin, macrolide, third‐generation cephalosporin and combinations, 78.5%, 83.9%, 93.6% and 86.0% of neonates were discharged alive without severe morbidity. The administration of third‐generation cephalosporin or any E. coli‐targeting combinations was associated with improved survival without severe morbidity (adjusted risk ratio 1.25 [95% confidence interval 1.08–1.45] and 1.10 [95 % confidence interval 1.01–1.20], respectively) compared with amoxicillin. We evidenced no increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen.

Conclusion

In preterm premature rupture of membranes at 24–31 weeks, antibiotic prophylaxis based on third‐generation cephalosporin may be associated with improved survival without severe neonatal morbidity when compared with amoxicillin, with no evidence of increase in neonatal sepsis related to third‐generation cephalosporin‐resistant pathogen.

Tweetable Abstract

Antibiotic prophylaxis after PPROM at 24–31 weeks: 3rd‐generation cephalosporins associated with improved neonatal outcomes.

Antibiotic prophylaxis after PPROM at 24–31 weeks: 3rd‐generation cephalosporins associated with improved neonatal outcomes.

Antibiotic Susceptibility of Escherichia coli Among Infants Admitted to Neonatal Intensive Care Units Across the US From 2009 to 2017

Importance

Escherichia coli is a leading cause of serious infection among term and preterm newborn infants. Surveillance of antibiotic susceptibility patterns of E coli among infants admitted to neonatal intensive care units should inform empirical antibiotic administration.

Objective

To assess the epidemiologic characteristics and antibiotic susceptibility patterns of E coli in infants admitted to neonatal intensive care units in the US over time.

Design, Setting, and Participants

This retrospective cohort study used the Premier Health Database, a comprehensive administrative database of inpatient encounters from academic and community hospitals across the US. Participants included newborn infants admitted to centers contributing microbiology data from January 1, 2009, to December 31, 2017, with E coli isolated from blood, cerebrospinal fluid, or urine cultures. Data were collected and analyzed from December 1, 2018, to November 30, 2019.

Main Outcomes and Measures

Changes in annual antibiotic susceptibility of E coli during the study period. The proportion of infants with nonsusceptible organisms (resistant or intermediate susceptibility) in antibiotic categories by year, birth weight, infection source, and timing of infection and patient and center characteristics associated with neonatal E coli infection and antibiotic susceptibility were assessed.

Results

A total of 721 infants (434 male [60.2%]; median age at E coli infection, 14 days [interquartile range, 1-33 days]) from 69 centers had at least 1 episode of E coli infection and available susceptibility results. No significant changes were observed over time in the overall annual proportions of antibiotic nonsusceptibility to ampicillin (mean [SD], 66.8% [1.5%]; range, 63.3% to 68.6%; estimated yearly change, -0.28% [95% CI, -1.75% to 1.18%]), nonsusceptibility to aminoglycosides (mean [SD], 16.8% [4.5%]; range, 10.7% to 23.2%; estimated yearly change, -0.85% [95% CI, -1.93% to 0.23%]), or extended-spectrum β-lactamase phenotype (mean [SD], 5.0% [3.7%]; range, 0% to 11.1%; estimated yearly change, 0.46% [95% CI, -0.18% to 1.11%]). No isolates with nonsusceptibility to carbapenems were identified. Among 218 infants with early-onset infection, 22 (10.1%) had isolates with nonsusceptibility to both ampicillin and gentamicin, the antibiotics most commonly administered to newborns as empirical therapy.

Conclusions and Relevance

In this cohort study, nonsusceptibility to commonly administered antibiotics was found in substantial proportions of neonatal E coli isolates, with no significant change from 2009 to 2017. These findings may inform empirical antibiotic choices for newborn infants.

Preventing early-onset group B streptococcal sepsis: clinical risk factor-based screening or culture-based screening?

INTRODUCTION

Two strategies are available for prevention of early-onset group B streptococcal (GBS) sepsis - clinical risk factor-based screening and routine culture-based screening of pregnant women for GBS colonisation. In our hospital, we switched from the former to the latter approach in 2014.

METHODS

We compared the incidence of early-onset GBS sepsis during 2001-2015 between infants born to pregnant women who were screened for GBS colonisation and those born to women who were not screened.

RESULTS

Among 41,143 live births, there were nine cases of early-onset GBS sepsis. All infants with GBS sepsis were born to pregnant women who were not screened for GBS colonisation. The incidence of early-onset GBS sepsis among infants of women who were not screened was 0.41 per 1,000 live births (95% confidence interval [CI] 0.19-0.77) when compared to infants of women who were screened, for whom the sepsis incidence was zero per 1,000 live births (95% CI 0-0.19; p = 0.005).

CONCLUSION

Our data suggests that routine culture-based screening of pregnant women for GBS colonisation is a better preventive strategy for early-onset GBS sepsis in neonates when compared to clinical risk factor-based screening.

Screening-based and Risk-based Strategy for the Prevention of Early-onset Group B Streptococcus/Non-group B Streptococcus Sepsis in the Neonate: A Systematic Review and Meta-analysis

BACKGROUND

Screening-based and risk-based strategies are the 2 strategies for preventing group B streptococcus (GBS) diseases in neonates. We aimed to compare the effects of these 2 strategies in reducing the incidence of early-onset GBS sepsis (GBS-EOS) and their effects on the incidence of non-GBS sepsis.

METHODS

PubMed, Embase, Web of Science and The Cochrane Central Register of Controlled Trials were searched for the period from January 1, 1996, to December 31, 2018. Randomized controlled trials and cohort studies that compared the effects of risk-based and screening-based strategies were eligible for the meta-analysis. The I statistic was used for assessing the statistical heterogeneity across studies. Pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs) were calculated using the random effects model.

RESULTS

There were 18 cohort studies comparing the incidence of GBS-EOS between the 2 strategies, involving a total of 604,869 newborns and 791 GBS-EOS cases. The heterogeneity across studies was moderate (I = 45%), and the pooled analysis yielded a 55% decreased risk of GBS-EOS for screening-based versus risk-based strategy (RR = 0.45; 95% CI: 0.34-0.59). For total early onset non-GBS sepsis (non-GBS-EOS), 7 studies with low heterogeneity (I = 18%) had a pooled RR of 0.91 (95% CI: 0.74-1.11), whereas for ampicillin resistant Escherichia coli-EOS, a subgroup of non-GBS-EOS, 3 studies with very low heterogeneity (I = 0%) had a pooled RR of 1.28 (95% CI: 0.74-2.21) for screening-based strategy compared with risk-based strategy.

CONCLUSIONS

Compared with risk-based strategy, screening-based prophylaxis was associated with a reduced risk of GBS-EOS.

Clinical Effects and Outcomes After Polymyxin B-Immobilized Fiber Column Direct Hemoperfusion Treatment for Septic Shock in Preterm Neonates

OBJECTIVES

To compare the effectiveness and mortality of early-onset sepsis or late-onset sepsis treatments with polymyxin B-immobilized fiber column direct hemoperfusion in terms of effectiveness and mortality in preterm infants with septic shock.

DESIGN

Retrospective cohort study.

SETTING

Neonatal ICU within a tertiary care hospital.

PATIENTS

Of 1,115 patients, 49 had blood culture-proven sepsis between January 2013 and December 2018; six and five patients with septic shock had undergone polymyxin B-immobilized fiber column direct hemoperfusion treatment for early-onset sepsis (early-onset sepsis group) and late-onset sepsis (late-onset sepsis group), respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Baseline demographic characteristics of both groups were similar. The time from decision to treatment induction was significantly shorter in the early-onset sepsis group than that in the late-onset sepsis group (p = 0.008). The mortality rate after 28 days of treatment and the hospital mortality were significantly lower in the early-onset sepsis group than in the late-onset sepsis group (p = 0.026 and 0.015, respectively). The PaO2/FIO2 ratio was significantly higher in the early-onset sepsis group than in the late-onset sepsis group at the end of the treatment (p = 0.035). In addition, median arterial-to-alveolar oxygen tension ratio significantly improved from 0.19 to 0.55, and median blood pressure also significantly improved from 32.5 to 40.0 mm Hg after the treatment in the early-onset sepsis group. Interleukin-6 levels significantly decreased after treatment in the early-onset sepsis group (p = 0.037). The Pediatric Risk of Mortality III score was similar between the early-onset sepsis and late-onset sepsis groups before and after the treatment. Intraventricular hemorrhage events occurred in both groups, but with no significant differences (p = 0.175).

CONCLUSIONS

Polymyxin B-immobilized fiber column direct hemoperfusion treatment for preterm infants with septic shock due to early-onset sepsis is associated with earlier hemodynamic and respiratory status improvements and with lower mortality than that due to late-onset sepsis. Early neonatal septic shock detection and polymyxin B-immobilized fiber column direct hemoperfusion induction may improve the prognosis of affected infants.

Sepsis calculator for neonatal early onset sepsis - a systematic review and meta-analysis

BACKGROUND

Over investigation and overuse of empirical antibiotics is a concern in management of neonatal early onset sepsis (EOS) using the Centers for Disease Control and Prevention guidelines. "Sepsis calculator" is a risk-based prediction model for managing neonates at risk of EOS.

OBJECTIVE

To compare outcomes of neonatal EOS using of sepsis calculator versus conventional approach.

METHODS

A systematic review of randomized controlled trials (RCT) and non-RCTs reporting on outcomes after implementation of sepsis calculator for EOS for neonates >34-week gestation was conducted using the Cochrane methodology. Databases PubMed, CINAHL, Embase, Cochrane Central library and Google Scholar were searched in May 2019. Primary outcomes were antibiotics usage and laboratory tests for managing EOS. Secondary outcomes included hospital admissions and readmissions, blood culture positive EOS and mortality. The level of evidence (LOE) was summarized using the GRADE guidelines.

RESULTS

A total of 387 articles were retrieved after initial search. Six high quality non-RCTs fulfilled inclusion criteria. Meta-analysis (random effects model) showed that implementation of sepsis calculator was associated with reduced antibiotic usage [N = 172,385; OR = 0.22 (0.14-0.36); p < .00001; heterogeneity (I²) = 97%, Number needed to treat (NNT): 22], laboratory tests [N = 168,432; OR = 0.14 (0.08-0.27); p < .00001; I² = 99%, NNT = 8], and admissions to neonatal unit [N = 16,628; OR = 0.24 (0.11-0.51); p = .0002; I² = 98%, NNT = 7]; LOE: moderate. There was no difference in mortality, culture positive EOS, and readmissions.

CONCLUSION

Moderate quality evidence indicates that the implementation of a sepsis calculator was associated with reduced usage of antibiotics, laboratory tests and admission to neonatal unit with no increase in mortality and readmissions.

Early-Onset Sepsis Risk Calculator Integration Into an Electronic Health Record in the Nursery

BACKGROUND AND OBJECTIVES

An early-onset sepsis (EOS) risk calculator tool to guide evaluation and treatment of infants at risk for sepsis has reduced antibiotic use without increased adverse outcomes. We performed an electronic health record (EHR)-driven quality improvement intervention to increase calculator use for infants admitted to a newborn nursery and reduce antibiotic treatment of infants at low risk for sepsis.

METHODS

This 2-phase intervention included programming (1) an EHR form containing calculator fields that were external to the infant's admission note, with nonautomatic access to the calculator, education for end-users, and reviewing risk scores in structured bedside rounds and (2) discrete data entry elements into the EHR admission form with a hyperlink to the calculator Web site. We used statistical process control to assess weekly entry of risk scores and antibiotic orders and interrupted time series to assess trend of antibiotic orders.

RESULTS

During phase 1 (duration, 14 months), a mean 59% of infants had EOS calculator scores entered. There was wide variability around the mean, with frequent crossing of weekly means beyond the 3σ control lines, indicating special-cause variation. During phase 2 (duration, 2 years), mean frequency of EOS calculator use increased to 85% of infants, and variability around the mean was within the 3σ control lines. The frequency of antibiotic orders decreased from preintervention (7%) to the final 6 months of phase 2 (1%, P < .001).

CONCLUSIONS

An EHR-driven quality improvement intervention increased EOS calculator use and reduced antibiotic orders, with no increase in adverse events.

Management of Infants at Risk for Group B Streptococcal Disease

Group B streptococcal (GBS) infection remains the most common cause of neonatal early-onset sepsis and a significant cause of late-onset sepsis among young infants. Administration of intrapartum antibiotic prophylaxis is the only currently available effective strategy for the prevention of perinatal GBS early-onset disease, and there is no effective approach for the prevention of late-onset disease. The American Academy of Pediatrics joins with the American College of Obstetricians and Gynecologists to reaffirm the use of universal antenatal microbiologic-based testing for the detection of maternal GBS colonization to facilitate appropriate administration of intrapartum antibiotic prophylaxis. The purpose of this clinical report is to provide neonatal clinicians with updated information regarding the epidemiology of GBS disease as well current recommendations for the evaluation of newborn infants at risk for GBS disease and for treatment of those with confirmed GBS infection. This clinical report is endorsed by the American College of Obstetricians and Gynecologists (ACOG), July 2019, and should be construed as ACOG clinical guidance.

Characterization of group B Streptococcus colonization in full-term and Late-Preterm neonates in Taiwan

BACKGROUND

Group B streptococcus (GBS) infections can be life-threatening in newborns. This study aimed to analyze GBS carriage status and genotypic diversity in healthy neonates after implementation of intrapartum antibiotic prophylaxis (IAP) in Taiwan.

METHODS

Newborns carrying GBS were identified from a screen of 500 newborns and followed up until their cultures turned negative. Their mothers' GBS screening data were reviewed. Molecular methods, including capsular serotyping, multilocus sequence typing and pulsed-field gel electrophoresis (PFGE), were used to analyze GBS isolates.

RESULTS

GBS colonization was detected at either the nose or anus in 11 of 500 healthy neonates (2.2%). In this group of 11 neonates, 4 had GBS serotypes II and III for 4-6 months, 1 had serotype V for 2 months, 6 had serotypes Ia, II, V, and VI for less than 1 month, and 1 had 2 different serotypes (serotypes V and II) at different times. The most prevalent serotype was II (33.3%), followed by Ia (25.0%), III (16.7%), V (16.7%), and VI (8.3%). The main sequence type was ST1 (50.0%), followed by ST19 (16.7%), ST23 (8.3%), ST24 (8.3%), ST103 (8.3%), and ST 231 (8.3%). All isolates were grouped into 5 PFGE clusters F, G, J, X, and Y, and all were susceptible to β-lactam antimicrobial agents.

CONCLUSIONS

GBS was carried in 2.2% (11/500) healthy newborns and persisted for 6 months in 3 neonates. This study makes clearer our understanding of GBS colonization, serotype distribution, and genotype distribution in healthy neonates.

Association of chorioamnionitis and its duration with neonatal morbidity and mortality

OBJECTIVE

To investigate the association of chorioamnionitis, and secondarily its duration, on neonatal adverse outcomes for infants born <34 weeks vs. ≥34 weeks.

STUDY DESIGN

A secondary analysis from the observational U.S. Consortium on Safe Labor Study. The exposure was chorioamnionitis, and secondarily, its estimated duration. The composite outcome included pneumonia, seizure, necrotizing enterocolitis, sepsis, periventricular/intraventricular/cerebral hemorrhage, mechanical ventilation, and neonatal death. Multivariable logistic regression with generalized estimating equations was used, stratified by gestational age at delivery.

RESULTS

Among 221,274 deliveries, the odds of the neonatal adverse outcome <34 weeks was 2-fold higher among infants exposed to chorioamnionitis vs. those who were not (62.0 vs. 47.7%; AOR: 1.86; 95%CI: 1.25-2.75), and was ~3.5-fold higher ≥34 weeks (9.2 vs. 2.5%; AOR: 3.34; 95% CI: 2.35-4.76). The estimated duration of chorioamnionitis did not change the above associations.

CONCLUSIONS

Chorioamnionitis was associated with an approximately 2- and 3.5-fold increased odds of neonatal adverse outcomes <34 and ≥34 weeks, respectively, regardless of its estimated duration.

Management of Neonates Born at ≤34 6/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis

Early-onset sepsis (EOS) remains a serious and often fatal illness among infants born preterm, particularly among newborn infants of the lowest gestational age. Currently, most preterm infants with very low birth weight are treated empirically with antibiotics for risk of EOS, often for prolonged periods, in the absence of a culture-confirmed infection. Retrospective studies have revealed that antibiotic exposures after birth are associated with multiple subsequent poor outcomes among preterm infants, making the risk/benefit balance of these antibiotic treatments uncertain. Gestational age is the strongest single predictor of EOS, and the majority of preterm births occur in the setting of other factors associated with risk of EOS, making it difficult to apply risk stratification strategies to preterm infants. Laboratory tests alone have a poor predictive value in preterm EOS. Delivery characteristics of extremely preterm infants present an opportunity to identify those with a lower risk of EOS and may inform decisions to initiate or extend antibiotic therapies. Our purpose for this clinical report is to provide a summary of the current epidemiology of preterm neonatal sepsis and provide guidance for the development of evidence-based approaches to sepsis risk assessment among preterm newborn infants.

[Antibiotic prophylaxis in preterm premature rupture of membranes: CNGOF preterm premature rupture of membranes guidelines]

OBJECTIVE

To analyse benefits and risks of antibiotic prophylaxis in the management of preterm premature rupture of membranes.

METHODS

PubMed and Cochrane Central databases search.

RESULTS

Streptoccoccus agalactiae (group B streptococcus) and Escherichia coli are the two main bacteria identified in early neonatal sepsis (EL3). Antibiotic prophylaxis at admission is associated with significant prolongation of pregnancy (EL2), reduction in neonatal morbidity (EL1) without impact on neonatal mortality (EL2). Co-amoxiclav could be associated with an increased risk for neonatal necrotising enterocolitis (EL2). Antibiotic prophylaxis at admission in women with preterm premature rupture of the membranes is recommended (Grade A). Monotherapy with amoxicillin, third generation cephalosporin and erythromycin can be used as well as combination of erythromycin and amoxicillin (Professional consensus) for 7 days (GradeC). Shorter treatment is possible when initial vaginal culture is negative (Professional consensus). Co-amxiclav, aminoglycosides, glycopeptides, first and second generation cephalosporin, clindamycin and metronidazole are not recommended (Professional consensus).

CONCLUSIONS

Antibiotic prophylaxis against Streptoccoccus agalactiae (group B streptococcus) and E. coli is recommended in women with preterm premature of the membranes (Grade A). Monotherapy with amoxicillin, third generation cephalosporin or erythromycin, as well as combination of erythromycin and amoxicillin are recommended (Professional consensus).

Aetiology of neonatal sepsis in Nigeria, and relevance of Group b streptococcus: A systematic review

BACKGROUND

Group B Streptococcus (GBS) causes invasive infections in neonates and has been implicated as a cause of prelabour rupture of membranes, preterm delivery and stillbirths. The success of phase II trials of polyvalent polysaccharide GBS vaccines indicates that these infections are potentially preventable. Nigeria is the most populous country in Africa with one of the highest birth rates, one of the highest neonatal sepsis incidence rates and one of the highest mortality rates in the world. Therefore, before the possible introduction of preventive strategies such as intrapartum antibiotic prophylaxis or GBS vaccine into Nigeria, it is vital that there is accurate data on the aetiology of neonatal sepsis and on the incidence of GBS neonatal sepsis in particular. The objective of this study was to determine the incidence and aetiology of neonatal sepsis in Nigeria with a focus on GBS sepsis and also to assess the potential impact of a GBS vaccine.

METHODS

A literature search was conducted on the databases of African journals online, PubMed and Google Scholar for works conducted between 1987 to 2017. Case reports, reviews, and studies not stating specific culture methods or specific bacteria isolated were excluded. Data extracted included; incidence of neonatal sepsis, method of blood culture, blood volume, sample size, bacterial agents isolated and history of antibiotic use. PRISMA guidelines were followed and modified Down's and Black criteria used to evaluate the quality of studies.

RESULTS

A total of 5,114 studies were reviewed for neonatal sepsis out of which 24 consisting of a total of 2,280 cases were selected for final review. Nine studies met criteria for assessment of hospital based incidence of neonatal sepsis representing 31,305 hospital births. The incidence of neonatal sepsis was 18.2/1000 livebirths with range from 7-55/1000 livebirths while the GBS incidence was 0.06/1000 livebirths with range from 0-2/1000 live births. We discovered various limitations such as identification techniques that could result in underestimation of the true incidence of GBS sepsis. Pathogens such as Klebsiella pneumoniae and Staphylococcus aureus were more commonly isolated than GBS.

IMPLICATIONS OF KEY FINDINGS

The hospital based incidence of neonatal sepsis was high at 18.2/1000 live births while that due to GBS was 0.06/1000 live births. The burden of neonatal sepsis, including that attributable to GBS is substantial and could be reduced by preventive strategies such as intrapartum antibiotic prophylaxis or GBS vaccine. There is however very sparse meaningful data currently. Well planned prospective studies with larger sample sizes, more advanced isolation and identification techniques and those following up invasive disease cases for possible short and long term sequelae are needed-not only prior to possible introduction of the vaccine to determine the baseline epidemiology, but also thereafter to monitor its impact on the population. Strategies need to be developed to also reduce the morbidity and mortality attributable to other bacteria that have an incidence even greater than that of GBS.

Aminoglycoside-Induced Cochleotoxicity: A Review

Aminoglycoside antibiotics are used as prophylaxis, or urgent treatment, for many life-threatening bacterial infections, including tuberculosis, sepsis, respiratory infections in cystic fibrosis, complex urinary tract infections and endocarditis. Although aminoglycosides are clinically-essential antibiotics, the mechanisms underlying their selective toxicity to the kidney and inner ear continue to be unraveled despite more than 70 years of investigation. The following mechanisms each contribute to aminoglycoside-induced toxicity after systemic administration: (1) drug trafficking across endothelial and epithelial barrier layers; (2) sensory cell uptake of these drugs; and (3) disruption of intracellular physiological pathways. Specific factors can increase the risk of drug-induced toxicity, including sustained exposure to higher levels of ambient sound, and selected therapeutic agents such as loop diuretics and glycopeptides. Serious bacterial infections (requiring life-saving aminoglycoside treatment) induce systemic inflammatory responses that also potentiate the degree of ototoxicity and permanent hearing loss. We discuss prospective clinical strategies to protect auditory and vestibular function from aminoglycoside ototoxicity, including reduced cochlear or sensory cell uptake of aminoglycosides, and otoprotection by ameliorating intracellular cytotoxicity.

Biomarkers for diagnosis of neonatal sepsis: a literature review

Sepsis is an important cause of mortality and morbidity in neonatal populations. There has been constant search of an ideal sepsis biomarker that have high sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), so that both the diagnosis and exclusion of neonatal sepsis can be made at the earliest possible and appropriate antibiotics can be started to neonate. Ideal sepsis biomarker will help in guiding us when not to start antibiotics in case of suspect sepsis and total duration of antibiotics course in case of proven sepsis. There are numerous sepsis biomarkers that have been evaluated for early detection of neonatal sepsis but till date there is no single ideal biomarker that fulfills all essential criteria's for being an ideal biomarker. The most commonly used biomarkers are C-reactive protein (CRP) and procalcitonin (PCT), but both have shown varied sensitivity, specificity, PPV and NPV in different studies. We conducted literature search for various neonatal sepsis biomarkers and this review article will cover briefly all the markers with current available evidence.

Clinical and Microbiologic Characteristics of Early-onset Sepsis Among Very Low Birth Weight Infants: Opportunities for Antibiotic Stewardship

BACKGROUND

Most very low birth weight (VLBW, birth weight <1500 g) infants receive empiric antibiotics for risk of early-onset sepsis (EOS). The objective of this study was to determine the characteristics of VLBW infants with culture-confirmed EOS at a single center during 25 years and to identify opportunities for antibiotic stewardship.

METHODS

Retrospective cohort study includes VLBW infants admitted from 1990 to 2015. EOS was defined as isolation of a pathogen in blood or cerebrospinal fluid culture obtained at <72 hours of age. Clinical and microbiologic characteristics of EOS case infants were obtained by review of medical, laboratory and administrative records. Blood culture, antibiotic initiation and maternal discharge code data were available for all VLBW infants born between 1999 and 2013.

RESULT

One-hundred nine EOS cases (20.5/1000 VLBW births) occurred during the study period. Preterm labor, preterm rupture of membranes and/or the obstetrical diagnosis of chorioamnionitis were present in 106/109 cases (97%). Obligate anaerobic organisms accounted for 16% of cases. Time to culture positivity was 36 hours for 88% and 48 hours for 98% of cases. From 1999 to 2013, 97% of VLBW infants were evaluated for EOS and 90% administered empiric antibiotics; 22% of these infants were born by cesarean section to mothers with preeclampsia and without preterm labor or chorioamnionitis and had a 12-fold lower incidence of EOS compared with the remaining infants.

CONCLUSION

Decisions to initiate and discontinue empiric antibiotics among VLBW infants can be informed by the delivery characteristics of infected infants and by local microbiologic data.

The role of Escherichia coli in reproductive health: state of the art

Escherichia coli is a well-known commensal of the normal intestinal microbiome that can also colonize the vaginal microbiome, usually without symptoms. However, E. coli can also be a highly virulent and frequently deadly pathogen. In this review, I will discuss the role E. coli has in reproductive health and disease.

Of the Phrensy: an update on the epidemiology and pathogenesis of bacterial meningitis in the pediatric population

In the past century, advances in antibiotics and vaccination have dramatically altered the incidence and clinical outcomes of bacterial meningitis. We review the shifting epidemiology of meningitis in children, including after the implementation of vaccines that target common meningitic pathogens and the introduction of intrapartum antibiotic prophylaxis offered to mothers colonized with Streptococcus agalactiae. We also discuss what is currently known about the pathogenesis of meningitis. Recent studies of the human microbiome have illustrated dynamic relationships of bacterial and viral populations with the host, which may potentiate the risk of bacterial meningitis.

Culture-proven early-onset neonatal sepsis in Arab states in the Gulf region: two-year prospective study

OBJECTIVE

To investigate the incidence and the pattern of causative organisms of culture-proven early-onset sepsis (EOS) in Arab states in the Gulf region.

METHODS

Five neonatal care units participated in this 2-year prospective study in Kuwait, the United Arab Emirates, and Saudi Arabia. Data were collected prospectively using a standardized data collection form. EOS was defined as the growth of a single potentially pathogenic organism from blood or cerebrospinal fluid in infants within 72h of birth, with clinical and laboratory findings consistent with infection.

RESULTS

Out of 67 474 live births, 102 cases of EOS occurred. The overall incidence of EOS was 1.5 (95% confidence interval 1.2-1.8) per 1000 live-births, ranging from 2.64 per 1000 live-births in Kuwait to 0.40 per 1000 live-births in King Abdulaziz Hospital in Saudi Arabia. The most common causative organism of EOS was group B Streptococcus (GBS; 60.0%), followed by Escherichia coli (13%). The incidence of invasive GBS disease was 0.90 per 1000 live-births overall and ranged from 1.4 per 1000 live-births in Kuwait to 0.6 per 1000 live-births in Dubai Hospital.

CONCLUSIONS

The incidence of EOS and the patterns of the causative organisms in the Arab states in the Gulf region are similar to those in developed countries before the era of intrapartum antibiotic prophylaxis. Efforts should be made to improve intrapartum antibiotic prophylaxis in the Arab state setting, which could avert large numbers of GBS infections.

Trends in US Hospital Stays for Listeriosis in Infants

BACKGROUND AND OBJECTIVES

Although listeriosis is rare in infants, it is common for young infants with suspected serious bacterial infection to be treated empirically with agents selected, in part, for their activity against Listeria monocytogenes. Our objectives were to describe the recent epidemiology of hospital discharges for listeriosis among infants in the United States and to precisely estimate the incidence of listeriosis according to infant age and meningitis status.

METHODS

We generated national estimates for listeriosis discharges in each of the 6 years for which samples were available in the Kids' Inpatient Database during the period 1997-2012. We used random-effects models to pool descriptive information and population rates across study years.

RESULTS

The cumulative number of US hospital discharges for listeriosis in infants was 344 (95% confidence interval [CI]: 290-397) over the 6 study years. The pooled annual incidence rate in infants (per 100,000 births) was 1.41 (95% CI: 1.01-1.80) after accounting for marked fluctuation in annual rates (range: 0.66-1.86; I2=79.3%). Discharges for listeriosis without meningitis were particularly rare after the first week of life. Our models predicted only 2.7 (95% CI: 1.1-4.2) and 1.8 (95% CI: 0.0-3.6) such discharges per year in infants admitted at ages 7 to 28 days and 29 to 364 days, respectively.

CONCLUSIONS

From the perspective of providing coverage against listeriosis, the routine practice of including ampicillin in the empirical treatment of febrile infants should be reevaluated for those older than 1 week without clinical evidence of meningitis.

Neonatal Escherichia coli Bloodstream Infections: Clinical Outcomes and Impact of Initial Antibiotic Therapy

BACKGROUND

Escherichia coli is a common cause of bloodstream infections (BSIs) in infants and is associated with high mortality and morbidity among survivors. The clinical significance of antibiotic resistance and timing of appropriate antimicrobial therapy in this population is poorly understood.

METHODS

We identified all infants with E. coli BSIs discharged from 77 neonatal intensive care units managed by the Pediatrix Medical Group in 2012. We used multivariable logistic regression to evaluate the association between 30-day mortality and ampicillin-resistant E. coli BSI, as well as the number of active empiric antimicrobial agents administered, controlling for gestational age, small-for-gestational age status, early-onset versus late-onset BSI, oxygen requirement, ventilator support and inotropic support on the day of the first positive blood culture.

RESULTS

We identified 258 episodes of E. coli BSI, including 123 (48%) ampicillin-resistant isolates. Unadjusted 30-day mortality did not significantly differ between infants with ampicillin-resistant versus ampicillin-susceptible E. coli BSI [11 of 123 (9%) vs. 7 of 135 (5%); P = 0.33; adjusted odds ratio = 1.37 (95% confidence interval: 0.39, 4.77)]. Among ampicillin-resistant E. coli BSIs, 30-day mortality was not significantly lower for infants treated with at least one empiric antimicrobial active against ampicillin-resistant E. coli versus infants receiving no active empiric agent [adjusted odds ratio = 1.50 (0.07, 33.6)].

CONCLUSIONS

In this population of infants with E. coli BSI, ampicillin resistance was not associated with significantly increased mortality. Among the subset of infants with ampicillin-resistant E. coli, appropriate empirical antibiotic therapy was not associated with lower mortality.

Bacterial meningitis in infants

Neonatal bacterial meningitis is uncommon but devastating. Morbidity among survivors remains high. The types and distribution of pathogens are related to gestational age, postnatal age, and geographic region. Confirming the diagnosis is difficult. Clinical signs are often subtle, lumbar punctures are frequently deferred, and cerebrospinal fluid (CSF) cultures can be compromised by prior antibiotic exposure. Infants with bacterial meningitis can have negative blood cultures and normal CSF parameters. Promising tests such as the polymerase chain reaction require further study. Prompt treatment with antibiotics is essential. Clinical trials investigating a vaccine for preventing neonatal Group B Streptococcus infections are ongoing.

Diagnosis and management of group B streptococcus in pregnancy

Group B streptococcus (GBS) can cause significant maternal and neonatal morbidity. Over the past 30 years, reductions in early-onset GBS neonatal sepsis in the United States have been attributable to the guidelines from the Centers for Disease Control and Prevention for antepartum screening and treating this organism during labor. This article highlights the clinical implications, screening, diagnosis, prophylactic interventions, and future therapies for mothers with GBS during the peripartum period.

Late-onset bloodstream infections in hospitalized term infants

BACKGROUND

The epidemiology and incidence of late-onset blood stream infections (BSIs) in premature infants have been described, but studies describing late-onset BSI in term infants are sparse. We sought to describe the pathogens, incidence, risk factors and mortality of late-onset BSI in hospitalized term infants.

METHODS

A cohort study was conducted of infants ≥37 weeks gestational age and ≤120 days of age discharged from Pediatrix Medical Group neonatal intensive care units from 1997 to 2010. We examined all cultures obtained from day of life 4-120 and used multivariable regression to assess risk factors for late-onset BSI.

RESULTS

We found a total of 206,019 infants cared for between day of life 4 and 120, and the incidence of late-onset BSI was 2.7/1000 admissions. We identified Gram-positive organisms in 64% of the cultures and Gram-negative organisms in 26%. We found a decreased risk of late-onset BSI in infants with the following characteristics: small for gestational age, delivery by Cesarean, antenatal antibiotic use and discharged in the later years of the study. Late-onset BSI increased the risk of death after controlling for confounders [odds ratio 8.43 (95% confidence interval 4.42-16.07)].

CONCLUSION

Our data highlight the importance of late-onset BSI in hospitalized term infants. We identified Gram-positive organisms as the most common pathogen, and late-onset BSI was an independent risk factor for death.

Early-onset neonatal sepsis

Early-onset sepsis remains a common and serious problem for neonates, especially preterm infants. Group B streptococcus (GBS) is the most common etiologic agent, while Escherichia coli is the most common cause of mortality. Current efforts toward maternal intrapartum antimicrobial prophylaxis have significantly reduced the rates of GBS disease but have been associated with increased rates of Gram-negative infections, especially among very-low-birth-weight infants. The diagnosis of neonatal sepsis is based on a combination of clinical presentation; the use of nonspecific markers, including C-reactive protein and procalcitonin (where available); blood cultures; and the use of molecular methods, including PCR. Cytokines, including interleukin 6 (IL-6), interleukin 8 (IL-8), gamma interferon (IFN-γ), and tumor necrosis factor alpha (TNF-α), and cell surface antigens, including soluble intercellular adhesion molecule (sICAM) and CD64, are also being increasingly examined for use as nonspecific screening measures for neonatal sepsis. Viruses, in particular enteroviruses, parechoviruses, and herpes simplex virus (HSV), should be considered in the differential diagnosis. Empirical treatment should be based on local patterns of antimicrobial resistance but typically consists of the use of ampicillin and gentamicin, or ampicillin and cefotaxime if meningitis is suspected, until the etiologic agent has been identified. Current research is focused primarily on development of vaccines against GBS.

Listeria and enterococcal infections in neonates 28 days of age and younger: is empiric parenteral ampicillin still indicated?

INTRODUCTION

Empiric parenteral ampicillin has traditionally been used to treat listeria and enterococcal serious bacterial infections (SBI) in neonates 28 days of age or younger. Anecdotal experience suggests that these infections are rare. Existing data suggest an increasing resistance to ampicillin. Guidelines advocating the routine use of empiric ampicillin may need to be revisited.

OBJECTIVE

This study aimed to describe the epidemiology and ampicillin sensitivity of listeria and enterococcal infections in neonates 28 days of age and younger who presented to 2 pediatric emergency departments (ED) in Michigan.

METHODS

We conducted a 2-center, retrospective chart review (2006-2010) of neonates 28 days of age or younger who were evaluated for SBI in the ED. We abstracted and compared relevant demographic, historical and physical details, laboratory test results, and antibiotic sensitivity patterns to ampicillin from the eligible patient records.

RESULTS

We identified SBI in 6% (72/1192) of neonates 28 days of age or younger who were evaluated for SBI, of which 0.08% (1/1192) neonates had enterococcal bacteremia and 0.08% (1/1192) neonates had listeria bacteremia. A total of 1.4% (15/1192) of patients had enterococcal urinary tract infection (UTI). Urinalysis is less helpful as a screening tool for enterococcal UTI when compared with Escherichia coli UTI (P < 0.001). Seventy-three percent (11/15) of urine isolates had an increase of minimal inhibitory concentrations, which indicate gradual development of resistance to ampicillin.

CONCLUSIONS

Listeria is an uncommon cause of neonatal SBI in febrile neonates who presented to the ED. Empiric use of ampicillin may need to be reconsidered if national data confirm very low listeria and enterococcal prevalence and high ampicillin resistance patterns.

2010 perinatal GBS prevention guideline and resource utilization

OBJECTIVES

To quantify differences in early-onset sepsis (EOS) evaluations, evaluation-associated resource utilization, and EOS cases detected, when comparing time periods before and after the implementation of an EOS algorithm based on the Centers for Disease Control and Prevention (CDC) 2010 guidelines for prevention of perinatal Group B Streptococcus (GBS) disease.

METHODS

Retrospective cohort study of infants born at ≥36 weeks' gestation from 2009 to 2012 in a single tertiary care center. One 12-month period during which EOS evaluations were based on the CDC 2002 guideline was compared with a second 12-month period during which EOS evaluations were based on the CDC 2010 guideline. A cost minimization analysis was performed to determine the EOS evaluation-associated costs and resources during each time period.

RESULTS

During the study periods, among well-appearing infants ≥36 weeks' gestation, EOS evaluations for inadequate GBS prophylaxis decreased from 32/1000 to <1/1000 live births; EOS evaluation-associated costs decreased by $6994 per 1000 live births; and EOS evaluation-associated work hours decreased by 29 per 1000 live births. We found no increase in EOS evaluations for other indications, total NICU admissions, frequency of infants evaluated for symptoms before hospital discharge, or incidence of EOS during the 2 study periods.

CONCLUSIONS

Implementation of an EOS algorithm based on CDC 2010 GBS guidelines resulted in a 25% decrease in EOS evaluations performed among well-appearing infants ≥36 weeks' gestation, attributable to decreased evaluation of infants born in the setting of inadequate indicated GBS prophylaxis. This resulted in significant changes in EOS evaluation-associated resource expenditures.

Stratification of risk of early-onset sepsis in newborns ≥ 34 weeks' gestation

OBJECTIVE

To define a quantitative stratification algorithm for the risk of early-onset sepsis (EOS) in newborns ≥ 34 weeks' gestation.

METHODS

We conducted a retrospective nested case-control study that used split validation. Data collected on each infant included sepsis risk at birth based on objective maternal factors, demographics, specific clinical milestones, and vital signs during the first 24 hours after birth. Using a combination of recursive partitioning and logistic regression, we developed a risk classification scheme for EOS on the derivation dataset. This scheme was then applied to the validation dataset.

RESULTS

Using a base population of 608,014 live births ≥ 34 weeks' gestation at 14 hospitals between 1993 and 2007, we identified all 350 EOS cases <72 hours of age and frequency matched them by hospital and year of birth to 1063 controls. Using maternal and neonatal data, we defined a risk stratification scheme that divided the neonatal population into 3 groups: treat empirically (4.1% of all live births, 60.8% of all EOS cases, sepsis incidence of 8.4/1000 live births), observe and evaluate (11.1% of births, 23.4% of cases, 1.2/1000), and continued observation (84.8% of births, 15.7% of cases, incidence 0.11/1000).

CONCLUSIONS

It is possible to combine objective maternal data with evolving objective neonatal clinical findings to define more efficient strategies for the evaluation and treatment of EOS in term and late preterm infants. Judicious application of our scheme could result in decreased antibiotic treatment in 80,000 to 240,000 US newborns each year.

The association of maternal intrapartum subfebrile temperature and adverse obstetric and neonatal outcomes

BACKGROUND

Subfebrile intrapartum maternal temperature is very common, yet there is sparse evidence regarding its causes or its effects on perinatal outcomes. We examined whether mild temperature elevation during labour is a risk marker for adverse obstetric and neonatal outcomes.

METHODS

A retrospective cohort analysis including 42 601 term, singleton live-births in two medical centres between 2003 and 2010 was performed. This study compared women who experienced a maximal intrapartum temperature of ≤37°C with women who experienced subfebrile intrapartum temperature (37.1-37.9°C). Adjusted risks for adverse obstetric and neonatal outcomes were calculated by using multivariable logistic regression models.

RESULTS

Compared with maternal temperature ≤ 37°C, subfebrile temperature was associated with higher rates of primary caesarean deliveries {adjusted odds ratios [aOR] = 1.36 [95% confidence interval (CI) 1.25, 1.49])} and assisted vaginal deliveries (aOR = 1.20 [95% CI 1.11, 1.30]), as well as with greater risks of early neonatal sepsis (aOR = 2.66 [95% CI 1.88, 3.77]), neonatal intensive care unit admissions (aOR = 1.40 [95% CI 1.08, 1.83]), and neonatal asphyxia or seizures (aOR = 3.18 [95% CI 1.51, 6.70]). Mildly elevated maternal intrapartum temperature (37.1-37.5°C) was also associated with adverse outcomes.

CONCLUSIONS

Maternal intrapartum subfebrile temperature may be an indicator of operative delivery and neonatal morbidity. Further research is needed to confirm these findings and to reveal underlying mechanisms.

Peripartum bacteremia in the era of group B streptococcus prophylaxis

OBJECTIVE

To define the microbial epidemiology and clinical risk factors associated with peripartum bacteremia in the era of group B streptococcus prophylaxis.

METHODS

We identified all cases of maternal bacteremia occurring during the peripartum time period (defined as from 7 days before delivery until 30 days after delivery) in a large maternity center from 2000 to 2008. Chart review was performed to determine the clinical factors associated with bacteremia.

RESULTS

During the study period, blood cultures were obtained from 1,295 febrile peripartum women (1.6% of all parturients); 172 of 1,295 febrile peripartum women (13.3%) had bacteremia (2.2 cases per 1,000 deliveries) with 194 microbial isolates and 1 yeast. The most frequent bacterial isolates were Escherichia coli (35.9%), enterococci (23.6%), and anaerobic species (9.2%); group B streptococcus was isolated in only eight cases (4.1%). Clinical diagnoses among infected women included endometritis (56%), chorioamnionitis (21%), and urosepsis (8%). Among women with endometritis, 77% underwent cesarean delivery (compared with vaginal delivery; relative risk [RR] 10.85, 95% confidence interval [CI] 6.75-17.45) and 39% delivered at less than 37 weeks of gestation (compared with 37 weeks or more; RR 3.21, 95% CI 2.42-4.25). Severe maternal complications of bacteremia were noted; six women required intensive care unit admission, five women had development of ileus, and one death occurred because of urosepsis.

CONCLUSION

In the era of group B streptococcus prophylaxis, E coli and enterococci are the most frequent bacteria isolated in peripartum bacteremia. Group B streptococcus accounted for only 4% of cases.

LEVEL OF EVIDENCE

III.

Results of a two-center, before and after study of piperacillin-tazobactam versus ampicillin and gentamicin as empiric therapy for suspected sepsis at birth in neonates ≤ 1500 g

OBJECTIVE

We changed from ampicillin and gentamicin (AG) to piperacillin-tazobactam (PT) for routine treatment of suspected early-onset sepsis. The rationale for this change included ototoxic and renal toxic effects of gentamicin, resistance to gentamicin in late-onset infections and emergence of ampicillin resistant Escherichia coli. A before and after study was designed before the start of PT administration to monitor whether PT was associated with altered outcomes within the 501 to 1500 g birth weight (Very Low Birth Weight) population.

METHOD

Both unmatched and matched comparisons of AG (2007 to 2009) and PT (2010 to 2011) exposed infants are reported. Cohorts were evaluated for initial effectiveness for congenital infections, subsequent morbidities and mortality.

RESULTS

Data from 714 patients were collected (499 AG and 215 PT in the unmatched and 301 AG and 183 PT in the matched cohorts). No significant differences in demographics or initial Apgar scores were noted in the unmatched or matched comparisons. There were significant differences in many of the outcomes of interest in both the matched and unmatched comparisons including less necrotizing enterocolitis (NEC) and less diaper rash with PT versus AG. The only adverse finding with PT was a small, but statistically significant elevation in alkaline phosphatase.

CONCLUSIONS

Use of PT as the initial empiric antibiotic for very low birth weight infants was not associated with adverse microbiological outcomes. There was no increase in major morbidities. Although outcomes were superior in ≤ 1500 g infants treated with PT when compared with AG, the study design does not allow us to conclude that others will see a reduction in NEC or diaper rash if they implement this alternative.

Neonatal infectious diseases: evaluation of neonatal sepsis

Neonatal sepsis remains a feared cause of morbidity and mortality in the neonatal period. Maternal, neonatal, and environmental factors are associated with risk of infection, and a combination of prevention strategies, judicious neonatal evaluation, and early initiation of therapy are required to prevent adverse outcomes. This article reviews recent trends in epidemiology and provides an update on risk factors, diagnostic methods, and management of neonatal sepsis.

Early-onset sepsis: a predictive model based on maternal risk factors

PURPOSE OF REVIEW

Neonatal early-onset sepsis (EOS) is a very low-incidence, but potentially fatal condition among term and late preterm newborns. EOS algorithms based on risk-factor threshold values result in evaluation and empiric antibiotic treatment of large numbers of uninfected newborns, leading to unnecessary antibiotic exposures and maternal/infant separation. Ideally, risk stratification should be quantitative, employ information conserving strategies, and be readily transferable to modern comprehensive electronic medical records.

RECENT FINDINGS

We performed a case-control study of infants born at or above 34 weeks' gestation with blood culture-proven EOS. We defined the relationship of established predictors to the risk of EOS, then used multivariate analyses and split validation to develop a predictive model using objective data. The model provides an estimation of sepsis risk that can identify the same proportion of EOS cases by evaluating fewer infants, as compared with algorithms based on subjective diagnoses and cut-off values for continuous predictors.

SUMMARY

An alternative approach to EOS risk assessment based only on objective data could decrease the number of infants evaluated and empirically treated for EOS, compared with currently recommended algorithms. Prospective evaluation is needed to determine the accuracy and safety of using the sepsis risk model to guide clinical decision-making.

Neonatal early-onset sepsis evaluations among well-appearing infants: projected impact of changes in CDC GBS guidelines

OBJECTIVE

To determine (a) the proportion of asymptomatic infants born at ≥35 weeks gestation evaluated for early-onset sepsis (EOS) and exposed to postnatal antibiotics; (b) reasons for and outcomes of the evaluations, and (c) anticipated changes when applying the Centers for Disease Control and Prevention (CDC) 2010 guidelines to this study population.

STUDY DESIGN

Retrospective cohort study of infants born at ≥35 weeks gestation in 2008-2009 in a large maternity center.

RESULT

Out of the 7226 infants that met the study criteria: 1062 (14.7%) were evaluated for EOS and half of those evaluated, received empiric antibiotics. 70.4% of evaluations were performed owing to maternal intrapartum fever, but 23% were prompted by inadequate Group B Streptococcus (GBS) prophylaxis alone. Three cases of blood culture-proven infection were identified.

CONCLUSION

Improved approaches are needed to identify asymptomatic infants who are at risk for EOS to decrease unnecessary evaluations and antibiotic exposure. Transition to the 2010 CDC GBS guidelines may eliminate a quarter of EOS evaluations among these infants.

No change in antibiotic susceptibility patterns in the neonatal ICU over two decades

OBJECTIVES

To identify trends in early-onset sepsis and late-onset sepsis neonatal rates and to evaluate the appropriateness of the empirical antibiotic protocols.

DESIGN

A 17-yr (1993-2009) analysis of positive blood and cerebrospinal fluid cultures.

SETTING

The two neonatal ICUs at the Hadassah- Hebrew University Medical Center.

RESULTS

During this period, 991 infants had at least one episode of either bacteremia or meningitis. The overall incidence of early-onset sepsis was 0.64 per 1,000 live births with a nonsignificant trend over the study period (p = 0.37). The overall incidence of late-onset sepsis was 7.5 per 100 admissions with a significant positive trend in the incidence rates (p = 0.021). The incidence of late-onset sepsis was 7.5 per 100 admissions with a significant positive trend in the prevalence rates (p = 0.021). The prevalence of early-onset group B Streptococcus bacteremia decreased significantly throughout the study period. Among late-onset sepsis, Gram-positive and fungi infection rates were stable over time, while Gram-negative infection rates showed a significant positive trend (p = 0.007). No significant change in the susceptibility rate of the isolated Gram-negative bacteria in late-onset sepsis for the common antibacterial drugs was found. About 85% and 90% of the isolated organisms were susceptible to our early-onset sepsis (ampicillin and gentamicin) and late-onset sepsis (vancomycin and cefotaxime) protocols, respectively, and these rates were stable over the study period (p = .1 and .55, respectively). Sepsis-related mortality was higher among Gram- negative sepsis cases resistant to our empiric antibiotic protocol.

CONCLUSIONS

Our empiric antibiotic protocols are appropriate despite their continuous use over the last 17 yrs. This may have been achieved by the use of a controlled antibiotic program and infection control efforts.

Correlation of bacterial type and antibiotic sensitivity with maternal antibiotic exposure in early-onset neonatal sepsis

BACKGROUND

Antibiotic administration during pregnancy as group B Streptococcus prophylaxis or as treatment of maternal conditions has become widespread.

OBJECTIVE

To assess whether bacterial type and antibiotic resistance in early-onset neonatal sepsis are associated with maternal antibiotic use.

METHODS

All positive blood and/or cerebrospinal fluid cultures (case-only study) and respective antibiotic sensitivities from newborns delivered in Shaare Zedek Medical Center, Jerusalem, Israel, between 01/01/1997 and 31/01/2007, taken during the first 72 h of life, were studied. Clinical and demographic data were obtained from the medical records of the infant/mother dyads. Three groups were defined by type of maternal antibiotic exposure: (1) no exposure, (2) intrapartum antibiotic prophylaxis (IAP), (3) antepartum antibiotic exposure during the month prior to delivery and extending into delivery or with subsequent IAP (AAE). Factors potentially associated with Gram-negative bacteremia and resistance to ampicillin were analyzed using multivariate logistic regression.

RESULTS

Ninety-seven different organisms grew from 94 infants (1.03 per 1,000 live births). By univariate analysis, AAE, gestational age ≤ 32 weeks, chorioamnionitis and rupture of membranes ≥ 18 h, were significantly associated with both Gram-negative sepsis and antibiotic resistance. By multivariate analysis, AAE was significantly associated with both outcomes, while gestational age ≤32 weeks was only associated with antibiotic resistance.

CONCLUSIONS

AAE for more than 24 h is associated with an increased proportion of Gram-negative organisms and ampicillin resistance in early-onset neonatal sepsis. Antepartum antibiotic therapy and its ramifications need to be continuously monitored and prospectively studied.

Neonatal stabilization and postresuscitation care

Neonatal mortality is a major health care concern worldwide. Neonatal resuscitation alone does not address most causes of neonatal mortality; caregivers need to be trained in both neonatal resuscitation and stabilization. Neonatal stabilization requires caregivers to evaluate whether babies are at-risk or unwell, to decide what interventions are required, and to act on those decisions. Several programs address neonatal stabilization in a variety of levels of care in both well-resourced and limited health care environments. This article suggests a shift in clinical, educational, and implementation science from a focus on resuscitation to one on the resuscitation-stabilization continuum.

Risk assessment in neonatal early onset sepsis

The incidence of neonatal early onset sepsis has declined with the widespread use of intrapartum antibiotic therapies, yet early onset sepsis remains a potentially fatal condition, particularly among very low birth-weight infants. Clinical signs of neonatal infection are nonspecific and may be absent in the immediate postnatal period. Maternal and infant clinical characteristics, as well as infant laboratory values, have been used to identify newborns at risk and to administer empiric antibiotic therapy to prevent progression to more severe illness. Such approaches result in the evaluation of approximately 15% of asymptomatic term and late preterm infants and of nearly all preterm infants. The development of multivariate predictive models may provide more accurate methods of identifying newborns at highest risk and allow for more limited newborn antibiotic exposures.